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( 2009 ) suggests that a “simple and genuine inquiry on the part of the counselor,
‘I would like to understand your question better,’ sets aside the question and
returns the focus on to the counselee” (p. 140).- Externalizing beliefs: Some patients may blame others for their situation. For
example, “This wouldn’t be so hard if I didn’t have to wait this long for an appoint-
ment with you!” or “I’d be able to decide about having Huntington’s testing if my
mother didn’t get so hysterical every time I mentioned it.” or “My doctor told me
I was NOT at risk for cancer, but you are telling me I am!” We suggest you side
step these externalizations as they are very difficult to modify and instead steer the
conversation toward the patient: “It sounds as if you’ve been feeling very troubled
about your condition”; “Do you feel guilty about burdening your mother with
your condition?”; or “I can imagine how difficult it is to talk about these risks.” - Patient believes fate, destiny, or a higher power brought about the situation:
Such patients may believe they are being punished for some transgression (which
they usually cannot articulate). Furthermore, some cultural groups believe
strongly in fate or karma. It is important to assess the extent to which this belief
underlies the patient’s experience. You might say, “I get the impression you think
having a child with spina bifida is some sort of punishment” or “I wonder if in
your culture, albinism is considered part of your destiny.” Later in this chapter,
we offer additional suggestions for working within these types of cultural
perspectives. - Unrealistic expectations: Some patients believe they should be able to make
decisions easily and without any distress, or they may think it is silly or abnormal
to feel so distressed. You could point out the unreasonableness of their expecta-
tions. For example, “Maybe you’re being a little hard on yourself by expecting to
have figured everything out already.” - Feeling too responsible: Patients may blame themselves for every aspect of their
situation. Patient: “I would never have miscarried if I’d quit drinking coffee.”
Counselor: “It almost seems like you’re looking for a reason to blame yourself.
Are you feeling responsible?” - Forceful family members: Lafans et al. ( 2003 ) interviewed prenatal genetic coun-
selors about how they managed problematic paternal involvement in prenatal
sessions. The prenatal counselors used advanced empathy to address overly
involved behaviors. For example, “...[I] tried to make him know I’d heard what
he was saying...] ‘Alright, you’re saying if your wife has this amnio and the baby
has Down Syndrome, there’s no way that you’re going to raise a baby with Down
Syndrome, and that you’ll leave her. Is that what you’re saying?’... once he got a
chance to talk about his strong feelings... I could turn to her and say ‘Ok, I hear
what your husband’s saying, and he’s very clear, but I get the feeling you feel
very differently’” (p. 228). - Couples or families may want you to take sides: To be effective, you need to
remain as supportive as you can toward each participant (Schoeffel et al. 2018 ).
You might say, “It seems like you want me to agree with you. It’s important that
you all have a chance to speak and to hear each other.” Relatedly, do not let
patients speak for each other. At the beginning of the session, state that it is
8 Responding to Patient Cues: Advanced Empathy and Confrontation Skills